Focal 100 Club Sign-Up

Membership number: (leave blank)

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Name:

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(to whom cheque should be made out for winnings)

‘Phone no:                                           Mobile:

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Postal address:

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Post Code:

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E-mail address:

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I/we understand that Focal will forward the completed Standing Order Mandate to the bank indicated and that £2.00 will be taken from my/our account on the first business day of each month or a sum of £24.00 to be paid annually by cheque or standing order into the Focal account until I/we advise the bank otherwise.

I/we agree that, if we wish to cancel this Standing Order, I/we will also inform Focal of this decision.

Signature                                                  Date

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Please return this form to Stuart Phipps, 12 Walton Avenue, Twyford, Banbury, Oxfordshire, OX17 4LB or Email: [email protected] together with your Standing Order Mandate/cheque so we can update our records.

Thank you for your support and good luck!

 

STANDING ORDER MANDATE

YOUR DETAILS:

Full name:

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Address:

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Post Code:

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Bank name:

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Bank address:

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Post Code:

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Sort Code:      –      –                Account Number:

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PLEASE PAY:

Account name:  Friends of the Community of Adderbury Library

Bank:   Lloyds Bank plc, 14 High Street, Banbury, Oxon  OX16 5EF

Sort Code:    30-90-42       Account Number:   07291653

Date of first regular payment:

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Amount and frequency thereafter (select one of these):

£2.00 monthly                                 £24.00 annually

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Payment reference: (Initial & surname)

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Until further notice in writing.

〈    〉  Please tick if you are a UK tax payer and wish Focal to claim Gift Aid on your payments

Signature                                                          Date

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